Family Planning Annual Health History Form
ADVERTISEMENT
1
2Family Planning Annual Health History
Name:
Date of Birth:
Date:
Female Medical History
Last Rubella Vaccination Date: ___________
First day of last period_____________
Average length of Periods in Days ______
Age of Onset of Periods_________________
Flow is:
Light
Moderate
Heavy
Bleeding between periods?
Yes
No
Cramps:
Always
Sometimes
Never
Bleeding after intercourse?
Yes
No
When was last normal period? _________
Date of last Pap Smear: ______________________
Was Pap Smear Normal?
Yes
No
If no, what was the abnormality? ________________________________________________________________
Date of last Mammogram:___________ Where was the Mammogram done:______________________________
Normal?
Yes
No If no, what was the Abnormality: _______________________________________
Did your Mother ever take DES (Diethylstilbestrol)?
Yes
No
Female Obstetric History
Number of Elective Abortions:
Number of Pregnancies
Number of Living Children:
Number of Live Births
Pregnancy Complications:
Number of Premature Births
Age at First Pregnancy_____ Date of Last Pregnancy__________
Number of Spontaneous Abortions (Miscarriages)
Male Medical History
Do you have difficulty urinating?
Yes
No
Dribbling
Yes
No
Discharge?
Yes
No
Female and Male Sexual History
Currently Sexually active?
Yes
No
Current Partner(s) Information:
Sexual Orientation_____________
# of Current Partners?_____
Age at Onset of Sexual Activity: ______
# of Lifetime Partners?____
Types of Sex
Vaginal
Oral Insertive
Oral Receptive
Birth Control Methods Used by Partner?__________________
Rectal Receptive
Rectal Insertive
Uses Injectable Drugs?
Yes
No
Number of Sexual Partners in last 6 months: ______
Has a history of Sexually Transmitted Infections, including HIV
# of Male Lifetime Partners?____
Infections:______________________________________
# of Female Lifetime Partners?____
Partner sexual Orientation: _______________
Sex of Current Partner: ____________ Current Age of Partner?_____
Does your partner have high risk sexual practices?
Yes
No
Last Sexual Encounter? ________
Has your partner been convicted of a sexual offense?
Yes
No
Use street/recreational drugs?
Yes
No
Is your partner required to register as a sex offender?
Yes
No
Do you practice safe sex?
Yes
No
How_______________________________________
Female and Male Contraceptive History
Current Method of Contraception: ____________________________ Length of time using Current Method: __________________
Any Problems with Current Method: _______________________________________________________________
Want to Change Method?
Yes
No
If yes, which method do you want to change to?______________________________
Methods Previously
Problems
Methods Previously Used
Problems
Methods Previously Used
Problems
Used
Abstinence
Injection/Depo
Spermicide
Condoms
Norplant
Sterilization
Diaphragm
Patch
IUD
Implanon
Pills
Other:_____________
Intimate Partner, Domestic Violence and Human Trafficking History
Are you currently a victim of Intimate Partner or Domestic Violence by being Forced or Sexually Abused, emotionally abused, or being
threatened with physical harm?
Yes
No
Have you ever been Physically or Sexually Abused?
Yes
No
If yes, explain:_______________________________________________________________________
Do you feel safe in your home and neighborhood?
Yes
No
If No, explain: ________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical